As Cykert and colleagues⁹ point out, patients are most concerned about their functional outcome following a major operation such as pulmonary resection, esophagectomy, or chest wall resection. They fear being limited in physical activity, having a bed-to-chair existence, and requiring complete assistance with activities of daily living. They do not seem to fear postoperative atelectasis, pneumonia, 3 days of mechanical ventilation, or even death. However, nonparticipation by the patient in rehabilitation in the postoperative period may lead to postoperative atelectasis and pneumonia, which can then lead to significant respiratory compromise and some of the dreaded outcomes patients want to avoid. According to Wright and colleagues,⁴³ the most common problems delaying discharge from the hospital include inadequate pain control, prolonged air leak, severe nausea, fever, debility, and arrhythmias (Table 41-1). Efforts to improve the patient’s preparation prior to the day of operation should be directed at preventing complications that would lead to limited physical function.

To achieve the best participation in patients’ postoperative care, the patient and family should be as fully informed as possible. When both patient and family know what to expect, they are better prepared to deal with problems as they arise. The surgeon should have frank and open discussions with the patient and family concerning the anticipated outcome and expected postoperative problems, along with the usual measures to combat those problems. Such discussions help the patient and family understand that the postoperative course may not be smooth and that aggressive measures may be required to achieve ultimate recovery.

Studies such as those by Turner and Williams³⁸ and Hekkenberg and colleagues²² show that patients retain only about half of what is discussed, so repeated sessions may be necessary to ensure that the perioperative journey is fully anticipated. Included in these discussions should be planning for what happens
after hospitalization. Involvement of social services at the time of scheduling the operation will facilitate a smooth transition from the acute care setting.

If surgical intervention is elective, a short period of preparation (preferably 3 weeks) may be beneficial if directed at improving the patient’s physical status and specifically at pulmonary preparation, conditioning exercises, and nutrition. In 1979, Gracey and colleagues¹⁷ studied 157 patients about to undergo a major operation. They administered a standard pulmonary preparation program used at that time and found that complications were significantly reduced but also that postoperative pulmonary complications were related to the extent of the operation. They drew no specific conclusions.

In 1999, Debigare and associates¹⁰ studied preparation for lung volume reduction procedures. Because many patients traveled a great distance, the investigators devised a home exercise training program that included incentive spirometry, muscle exercises, and aerobic training. It began with detailed teaching and follow-up and was ensured through weekly phone calls and a diary filled out by each patient. As a result, there was a significant increase in the 6-minute walk test, quality-of-life perception, peak work rate, peak oxygen consumption, endurance time, and muscle strength; it was therefore concluded that such training was beneficial when time permits a delay in the timing of the operation.

Smoking cessation has always been considered an important issue in preparation for an operation. However, the evidence shows that the effects of cigarette smoking linger long after cessation and that inordinately long preoperative delays would be necessary to achieve any significant improvement. The Lung Health Study Research Group has published many reports concerning the effects of smoking cessation. Anthonisen and colleagues³ reported the results of one of the aforementioned group’s studies involving individuals with documented early chronic obstructive pulmonary disease (COPD) who stopped smoking; they experienced improvement of lung function, with the greatest benefit being noted in the first year. No conclusions can be drawn concerning the early effects of smoking cessation, because the investigators’ first observation point was 3 months after intervention.

In a study of rats exposed to smoking followed by cessation, Hannan and associates²¹ found that smoking significantly decreased the fluidity of alveolar macrophages, which persisted up to 18 weeks after cessation. Jeffery and colleagues²⁶ studied tracheal surface epithelium and ciliary function in rats exposed to smoke. They found an increase in the number of cilia in intraluminal mucus and in the presence of secretory cells of types IV (i.e., merocrine) and V (i.e., apocrine). They also found that the area of trachea covered by cilia, as determined by point counting, increased significantly.

Verra and associates⁴⁰ studied the cilia of human individuals who were smokers, ex-smokers, or nonsmokers. They noted that the percentage of axonemal ultrastructural abnormalities was higher in smokers and ex-smokers than in nonsmokers or control subjects, a condition that seemed to persist long after smoking cessation. The axonemal ultrastructural abnormalities were polymorphic, characteristic of acquired ultrastructural changes. These results suggest that chronic smoking may induce an increased number of abnormal cilia, which may lead to impaired clearance of mucus.

Bertram and Rogers⁵ noted that epithelial recovery can occur for smokers who have quit for 2 years. Andersson and associates² studied bronchoalveolar lavage fluid from former smokers and found that Clara cell secretory protein was increased in smokers and remained elevated for up to 12 months after smoking cessation. Despite the lack of firm evidence, it is still recommended that patients quit smoking for as long as possible prior to operation.

Some data suggest that cessation of smoking leads to higher postoperative complications. This is based on the fact that patients have increased secretions early after cessation. However, in 2005, Barrera and colleagues⁴ studied smokers undergoing thoracotomy at Memorial Sloan-Kettering Cancer Center. They found no difference in pulmonary complications among recent quitters versus continuing smokers. Only patients with >60 pack-years and those with a significantly reduced diffusion capacity had higher risks of pulmonary complications. The investigators concluded that it was safe to quit at any time before operation.

Preoperative nutritional repletion remains controversial. Preoperative assessment of nutrition cannot be done with any one simple test. The best assessment is weight loss and adequacy of nutritional intake. In 1977, Fogliani and coworkers¹³ declared that they could give patients with esophageal cancer sufficient nutrition and return them to positive nitrogen balance using a diet consisting of an average of 2,000 to 2,600 calories as carbo- hydrate and lipids and 12 to 14 g of nitrogen. Lim and colleagues²⁸ used total parenteral nutrition to achieve positive nitrogen balance but noted that this took a minimum of 4 weeks. Despite this difference, the goal for preoperative preparation of the patient is to maintain nutrition at all possible costs to prevent additional weight loss before operation and to schedule the procedure as soon as the patient is prepared.

Preoperative medications should be continued up to the time of operation. The only exceptions are anticoagulant medications. Patients on warfarin (Coumadin), low-molecular-weight heparin, unfractionated heparin, or clopidogrel (Plavix) should stop their medications long enough prior to the procedure that the effects of these drugs are minimal. Cessation of aspirin is an individual preference. For pulmonary and esophageal surgery, there is no evidence that aspirin increases bleeding. There is also no evidence that the addition of preoperative short-term bronchodilators changes operative outcomes.

Perioperative management and the conduct of anesthesia are discussed in Chapters 21 and 22. However, several points are worth emphasizing. Management of anesthesia begins with the proper preparation of patients so that they will be able to emerge smoothly and promptly after the end of the operation. Avoidance of long-acting narcotics and paralytics is essential to this philosophy. The anesthesiologist should be judicious with fluids, keeping the additional crystalloid above fluid losses to 500 to 750 mL. Pain control is extremely important to the early mobilization of patients. Regardless of approach (epidural, continuous bupivacaine infusion, patient-controlled analgesia, or a combination), the goal is continuous pain relief sufficient to allow the patient to participate in pulmonary rehabilitation and experience early mobilization without significant restrictions placed by the method of analgesia.

Patients should go to a unit familiar with the management of patients who have undergone complex thoracic surgery. The initial setting should be monitored, and the nurse–patient ratio in the early postoperative period should be sufficiently high to permit assessment and intervention as needed as well as sufficient staff for early mobilization. Each institution defines the staffing ratio differently, but a 1:2 nurse–patient ratio is ideal. Automatic admission to the intensive care unit is a waste of resources.

Surgeons now have several different options for draining the chest. Although actual tube choice is beyond the scope of this chapter, most surgeons still place one tube anteriorly and one posteriorly in the chest. The tubes are attached to a drainage system that permits one-way drainage only, with a portion of the device set up to collect fluid. These devices use a variety of valves or liquid to establish a one-way system. All of the collection systems are designed to provide suction on the tubes if the surgeon desires. In the past, the manufacture of these devices was governed by a single American standard published by the American Society for Testing and Materials¹ that specified the minimal safety and performance standards for pleural and mediastinal drainage. In 2003, this standard was withdrawn by the society and replaced by the three standards on suction devices written by the International Standards Organization.^23,24,25 These new standards specify looser criteria but apply the standards worldwide.

In the past, all chest tubes were placed on suction at 20 cm H₂O. In recent years, the advisability of the ubiquitous use of suction has been questioned. Several investigators—including the author,³⁰ Cerfolio,⁶ and Wain⁴¹ and their respective coworkers—contend that if the lung is fully expanded with the tube on no suction, the patient will do well. Now there is more individual preference concerning chest tube suction.

Regardless of types of chest tubes and the use of suction, the drainage tubes must be assessed at least daily for patency, function, air leakage, and drainage. Inspection of the tube and drainage system for clots or blockages assures patency. Obstructions are removed by “stripping” the tubing. This is accomplished by occluding the tubing and pulling it away from the patient to produce a local suction effect. If this does not work, a balloon-tipped catheter may be passed up the tubing to remove the clot, or a suction catheter may be used for the same purpose.

A functioning tube is one that shows variation in the fluid within it when the patient breathes quietly. This may be observed while talking with the patient at the bedside. Good respiratory variation indicates proper functioning of the tube. Limited changes in the level of the fluid in those drainage systems with a water column may indicate partial blockage, and the tubing may require further stripping. The tubing should be placed so that it does not coil, leaving low points to collect fluid. Such collections impede fluid flow and may cause positive pressure to build up in the tubing and back up into the patient.

Air leakage is assessed by observing the water-seal chamber on the drainage device. Air leakage should first be assessed off suction at quiet respiration. Next the patient is asked to cough and the chamber is observed. Finally, the patient may be placed back on suction if suction is being employed, and the chamber again observed. Several grading systems have been devised. In general, air leaks should be characterized by the force necessary to produce the air leak and the amount of the air leak. The smallest leak is an intermittent one produced on suction only, and the largest one is a continuous air leak. Newer devices being evaluated currently display the amount of air leak digitally.

Drainage should be measured daily and during the preceding 8 hours so that an estimate can be made concerning whether the rate of fluid drainage is increasing or decreasing. Nurses usually record the drainage in 8-hour shifts and provide a total daily drainage for the last three shifts. Also, the character of the drainage should be noted. Change in the character of the fluid from sanguinous to serous is usually a good sign. Change from serous to purulent connotes potential empyema. In planning the removal of a chest tube, the drainage must significantly decrease to levels acceptable to the surgeon. Although exact numbers are not scientifically verified for the amount of pleural fluid produced per day while a chest tube is in place, a convenient number is 3 mL/kg per day or 1 mL/kg every 8 hours. For the average patient, this would amount to 240 to 300 mL per day.

Chest tubes and drainage systems are intended to keep the lung expanded and prevent the development of a space. Once air leakage ceases and drainage has decreased to acceptable levels, the system has performed its function and should be removed. In an age of cost containment, this could be anytime after the operation. Wain and colleagues⁴¹ have noted that for
major pulmonary resections, the average length of time to chest tube removal was 4.5 days. This remains an operator-dependent variable and can still be decreased significantly. There is no scientific proof that a chest tube must be on suction for 2 days after operation followed by 2 days of water seal before it is removed.

Patients are encouraged to take their medicines with the exception of warfarin up to the time of surgery. However, most medications can be withheld safely for a few days postoperatively until normal metabolism and bowel function have returned. There is no indication for the use of prophylactic medications. The use of perioperative antibiotics for pulmonary or esophageal resection should be individualized, as Mangram and colleagues³³ reported in a guideline for prevention of surgical site infection sponsored by the Centers for Disease Control and Prevention. They noted that prophylactic antibiotics should be used for operations with an anticipated high infection rate or for those with severe or life-threatening consequences if infection occurs and that an antimicrobial agent should be selected based on published recommendations for a specific operation and efficacy against most common pathogens. In fact, Luchette and associates³¹ found, in a meta-analysis, that data supporting the use of prophylactic antibiotics for emergency thoracotomies and chest tubes were minimal; they recommended only 24 hours of antibiotics. A survey conducted by the author²⁹ showed that few surgeons used prophylactic antibiotics for thoracotomies. Despite the call for antibiotics at the time of the “surgical pause” or “time out,” prophylactic antibiotics are necessary only for cardiac, vascular, orthopedic, and colon procedures.